术前症状和手术时间窗对血管内治疗急性基底动脉闭塞患者预后的影响分析

Analysis of the effects of preoperative symptoms and surgical time window on the outcome of patients with acute basilar artery occlusion undergoing endovascular treatment

目的探讨术前症状和手术时间窗对血管内治疗急性基底动脉闭塞(BAO)患者预后的影响。方法回顾性分析2017年1月至2019年9月空军军医大学唐都医院神经外科行血管内治疗的42例急性BAO患者的临床资料。对所有患者术前行格拉斯哥昏迷评分(GCS)以评估症状严重程度,其中12例为9~15分(轻中度),18例为6~8分(重度),12例为3~5分(特重度)。发病至股动脉穿刺时间(手术时间窗),17例为0~6 h、16例为>6~9 h,9例为>9~24 h。术后即刻行脑血管造影,应用改良脑梗死溶栓分级(mTICI)评估血管再通情况,其中2b/3级为血管成功再通。术后36 h内复查头颅CT,以判断患者是否发生症状性脑出血。术后3个月对所有患者行门诊或电话随访,行改良Rankin量表评分(mRS)评估预后,0~3分定义为预后良好,其中0~2分生活可自理;4~6分定义为预后不良。进一步采用单因素和多因素logistic回归分析法判断术前症状严重程度和手术时间窗是否为影响患者预后的独立危险因素。结果42例患者中,血管成功再通38例(90.5%),其中35例为mTICI 3级,3例为2b级;血管未成功再通4例(9.5%),2例为mTICI 2a级,2例为mTICI 0级。住院期间3例(7.1%)患者死亡,其中2例术后呼吸、心跳骤停,考虑因脑干功能衰竭所致;另1例继发肺部感染呼吸衰竭死亡。1例(2.4%)患者出现症状性脑出血。39例患者的中位随访时间为3个月(1~4个月)。术后3个月,39例患者中,20例(51.3%)预后良好,其中17例生活可自理;19例(48.7%)预后不良,其中8例死亡。单因素分析结果显示,年龄和术前症状严重程度是影响患者预后的临床因素(均P<0.05)。进一步多因素logistic回归分析结果显示,术前出现特重度症状是影响患者预后的独立危险因素(OR=0.039,95%CI:0.004~0.404,P=0.007)。结论初步推测急性BAO患者的术前症状为特重度,血管内治疗的预后差;而手术时间窗不是影响血管内治疗急性BAO患者预后的独立危险因素。

Objective To investigate the effects of preoperative symptoms and surgical time window on the outcome of patients with acute basilar artery occlusion(BAO)undergoing endovascular therapy.Methods A retrospective study was conducted on the clinical data of 42 patients with acute BAO who underwent endovascular treatment at Department of Neurosurgery,Tangdu Hospital of Air Force Medical University from January 2017 to September 2019.The symptom severity of all patients was evaluated based on the Glasgow Coma Scale(GCS)prior to surgery,of which 12 cases were mild-medium(9-15 points),18 cases were severe(6-8 points),and 12 cases were extremely severe(3-5 pints).In terms of surgical time window,the time from onset to femoral artery puncture was 0-6 hours in 17 cases,>6-9 hours in 16 cases,and>9-24 hours in 9 cases.Modified thrombolysis in cerebral ischemia grade(mTICI)was used to evaluate recanalization post operation.Successful revascularization was defined as an mTICI of 2b or 3.CT reexamination was performed within 36 hours post operation to determine whether the patient had symptomatic intracerebral hemorrhage.All patients were followed up through outpatient clinic or telephone at 3 months post discharge.Modified Rankin Scale(mRS)was used to assess the patient′s outcome.A favorable clinical outcome was defined as an mRS of 0-3,functional independence was defined as an mRS of 0-2,and poor outcome was defined as an mRS of 4-6.Univariate and multivariate logistic regression analyses were used to determine whether preoperative symptoms and surgical time window were independent influencing factors of the outcome of patients.Results Among 42 patients,38(90.5%)achieved successful recanalization and consisted of 35 cases with the mTICI of 3 and 3 cases with the mTICI of 2b.Unsuccessfully recanalization was reported in 4 cases(9.5%),which consisted of 2 with the mTICI of 2a and 2 with the mTICI of 0.During hospitalization,3(7.1%)patients died.Among them,2 cases suffered postoperative breathing and cardiac arrest,considered to be caused by brain stem failure,and the remaining 1 died of respiratory failure due to secondary lung infection.Symptomatic intracerebral hemorrhage occurred in 1 case(2.9%).The median follow-up time of 39 patients was 3 months(1-4 months).At 3 months post discharge,20(51.3%)cases reported favorable clinical outcome and included 17 with functional independence,and 19(48.7%)had a poor outcome and included 8 deaths.Univariate analysis showed that age and the severity of preoperative symptoms were influencing factors of the patient′s outcome(both P<0.05).Further multivariate logistic regression analysis showed that extremely severe preoperative conditions(GCS:3-5)was an independent risk factor for poor outcome(OR=0.039,95%CI:0.004-0.404,P=0.007).Conclusions It has been preliminarily suggested that heavier preoperative symptoms in patients with acute BAO occlusion is predictive of worse outcome of endovascular treatment.Surgical time window does not seem to be an independent influencing factor of the outcome.